Provider Demographics
NPI:1164894929
Name:MANCILLA, MICHAEL (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MANCILLA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 NEW YORK AVE NW
Mailing Address - Street 2:# 211
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-4743
Mailing Address - Country:US
Mailing Address - Phone:202-234-2299
Mailing Address - Fax:
Practice Address - Street 1:437 NEW YORK AVE NW
Practice Address - Street 2:# 211
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-4743
Practice Address - Country:US
Practice Address - Phone:202-234-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3203181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical